Basic Information
| Provider Information | |||||||||
| NPI: | 1528127404 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | COLIN | ||||||||
| MiddleName: | MAURICE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | L.P.C. LCAS CSI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280012833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049832117 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2006 | ||||||||
| LastUpdateDate: | 07/24/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3775 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 1464 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 6103433 | 05 | NC | MEDICAID |